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Trigger warning: This article contains discussion of suicide It is 2024 and there are still no highly-effective treatment options for anorexia nervosa, and our understanding of the biological factors involved in eating disorders is far behind other fields within psychiatry. We are hoping that this is soon to change.   My name is Johanna, and I am a postdoctoral researcher working in the field of eating disorders. I’ve written multiple paper s on the topic, and the first sentence of any publication I write about anorexia nervosa always starts with the shocking reality that anorexia is one of the most fatal illnesses  across the spectrum of psychiatric disorders. The sentence might as well be copied and pasted. However, what is less known is that one of the driving factors of its high mortality rates is the high rate of suicide . Depression and hopelessness are extremely common experiences for people that experience an eating disorder.   These miserable statistics, commonly used to introduce this topic, can be counteracted by the promising news that we are beginning to understand a bit more about the biological reasons that may be behind the “stuckness” that so many people experience.   Stereotyped depictions of anorexia nervosa involve mainly white, middle-class, Western women from privileged upbringings. New research counteracts this stereotype, with the finding of a role for metabolic genes (which regulate chemical reactions that convert food to energy) leading to a reconceptualization of anorexia as a “metabo-psychiatric disorder” .   The brain is the hungriest organ in the body, using around 20% of our daily energy intake, and certain parts of our diet (e.g., healthy fats) are very important for brain health. When people lose large amounts of weight in their body, perhaps unsurprisingly, this culminates in weight loss in the brain too. In anorexia nervosa, this loss is around 6%, which is the greatest amount of loss across all of the psychiatric disorders . Other aspects of the biology change too, likely as an adaptation to weight loss. For example, one molecule that is particularly important for the growth and adaptation of brain cells, called “brain-derived neurotrophic factor” reduces . Luckily, evidence suggests that these changes are largely reversible with weight gain and nutritional reinstatement. However, it is clear that more approaches to promote brain recovery are needed.  The onset of depression is a common experience for people with anorexia, which may come from multiple places. For example, in the famous 1944 “Minnesota Starvation Experiment” , young men were starved for six months in order to learn about how best to refeed malnourished populations across Europe at the time. These previously healthy men not only developed obsessions around food, but also became extremely anxious and depressed.   Depression could also be a side effect of living with anorexia nervosa, for example the toll it takes on one’s psychosocial functioning and one’s ability to engage in everyday life (e.g., work, school, social relationships) as a result of obsessive thoughts, poor cognitive functioning and having life interrupted by frequent visits to services or hospitalisation.   The problem is that standard antidepressants are usually ineffective in people with anorexia. It has been speculated that starvation leads to a shortage of the amino acid tryptophan, which is present in most protein-based foods and cannot be created by the body by itself. Such nutrients are necessary for the production, storage and release of serotonin, the molecule which is believed to be decreased in depression. Therefore, there are no evidence-based methods  of helping alleviate depression in this population.   Ketamine is a drug that is traditionally used in medical settings as an anaesthetic. In much lower doses, ketamine has shown rapid antidepressant properties  and research looking at its use for treating depression has rapidly expanded in the last decade. One form of it has been licensed for use in treatment-resistant depression .   Ketamine can be given by vein, as an injection, through the nostrils, or swallowed as a capsule or liquid. Many studies have shown that ketamine has fast, but temporary, anti-depressant and anti-suicide effects. However, there are significant side effects that depend on the type of administration and the amount that is given. Dissociation, or feeling “detached from one’s surroundings” is a common side effect, as is feeling nauseous. Therefore, it is important that patients given ketamine for depression are closely monitored and are in a safe and medically-supervised environment.   Several studies have also found that ketamine may increase the brain-boosting molecule mentioned before, brain-derived neurotrophic factor . It also works via a different biological pathway than do usual anti-depressants.   Therefore, for several reasons we believe that it may have the potential to help reduce depression and help promote recovery in people with anorexia nervosa, and several case studies have shown promising initial evidence .   The first important step in the scientific process is to demonstrate the safety of this medication, as well as the likelihood that people want to take part in such a study. Excitingly, we will be running a small-scale study beginning in 2025  in order to gain data on this and to pave the way towards more research.   It is likely that there is no one-sized-fits-all approach to the treatment of anorexia nervosa, and other research teams are looking at using compounds such as psilocybin (a molecule derived from magic mushrooms) and metreleptin  (a synthetic form of the hormone leptin). I am not sure if I believe in a “wonder-drug” per se, but if shown to be effective, new evidence-based approaches to help people with this hard-to-treat and extremely distressing condition would be a huge step forward.

Part 1: Halting progress in body positivity Content warning: This article contains discussions surrounding weight loss and body image The body positivity movement , which began in the 1970s, brought forward a new and heart-warming era of learning to love the skin you’re in, promoting self-acceptance and not letting your physical appearance dictate your life. However, after years of progress, the 2024 Met Gala, dubbed by Twitter users as the “Ozempic Olympics”, reminded us that the obsession with thinness reminiscent of the early 2000’s is far from forgotten.   As we marvelled at the celebrities and judged their outfit choices, the smaller bodies which many stars flaunted had a lot of people questioning “who is on Ozempic?”. Originally designed as a treatment for diabetes , Ozempic is now soaring in popularity as the “magic fix” to aid in weight loss, and countless celebrities have been open about taking the medication, boasting about their success in losing weight.   As a PhD student in the field of mental health, and someone with personal experience with an eating disorder, I find the increasing use of this drug alarming. This prompted me to write a series of two articles, of which this is the first, to help people understand the potential benefits of Ozempic while also considering the issues surrounding its popularity and accessibility. In this introductory article, I will discuss what Ozempic is and how it is influencing societal views on body positivity. What is Ozempic and how does it work? Ozempic, which is administered by injection, is one of many drugs which contain the active ingredient , semaglutide. This ingredient mimics a natural hormone (a product coming from plant or animal sources) called glucagon-like peptide-1   (GLP-1), which stimulates the body to produce insulin. Therefore, this compound works to lower blood sugar levels, providing beneficial treatment to those suffering from type 2 diabetes.   However, Ozempic also delays the movement of food through the body, thus allowing people to feel fuller for longer. Further, GLP-1 also works by travelling to the brain and informing it that you are full. Therefore, by mimicking this hormone, Ozempic can make us feel full both physically and mentally. These effects have earned it the nickname ‘the skinny jab’ . Of course, the original point of this drug was not to make people ‘thinner’ per se, but for people with clinically-significant obesity it can have profound benefits. Aside from being an important treatment for diabetes, it can also lower the risk of cardiovascular disease and help people with obesity get to a healthy weight without the need for stomach surgery. Obesity is associated with a number of health risks , such as stroke, cardiac arrest and sleep apnoea, with many being reversed when weight is lost. Furthermore, bariatric surgery (involves making changes to your digestive system  to help you lose weight) can be dangerous and expensive, while Ozempic only requires a simple injection. Based on these facts, the FDA approved that Wegovy injections , which also contain semaglutide, could be prescribed specifically for weight loss in obese patients.   Accessibility of Ozempic and dangerous counterfeits The biggest concern with the increasing popularity of this drug is that people who do not need it are managing to access it. Indeed, people have been able to bypass face-to-face doctor approval by using online pharmacies , where they can obtain a prescription for Ozempic simply by lying about their Body Mass Index (BMI) (a way to broadly categorize a person based on tissue mass and height). Worryingly, according to an investigation undertaken by the Guardian , some of these pharmacies were even dispatching Ozempic to people who openly declared they were of a healthy weight.   Concerningly, due to the increase in these “off-label” prescriptions for weight loss, there has been a shortage of Ozempic  in parts of the US and across the UK. This means that people with diabetes, who need to be taking the drug regularly to control their insulin levels, are not able to access it.   Additionally, due to the shortage in the supply of Ozempic, online black markets have begun to create counterfeit semaglutide “diet kits”. The kits contain needles, along with a white powder and a liquid which are mixed before injection of the drug. A BBC news story  even reveals how a young girl bought one of these kits from a seller on Instagram, and after a few weeks of using the drug was taken to A&E due to severe vomiting, throwing up stomach acid, blood and white foam.   Halting the progress of the body positivity movement The rising use and popularity of these drugs pose threats that go beyond the potential physical dangers of misuse.   For years, we as a society have made significant progress in understanding body positivity and recognising that people come in different shapes and sizes, all of which are beautiful. This diversity is influenced by factors such as genetics, metabolic needs, daily expenditure, lifestyle, financial situation, and more. We've even seen a rise in plus-size influencers advocating for body positivity and normalising body-type variety in the media.   However, the rise in the use of Ozempic has revealed just how fragile this way of thinking really was. Now, we hear stories of celebrities like Boy George , Sharon Osbourne , Oprah Winfrey  and Elon Musk  who have all openly used the drug for weight loss, with Boy George even stating in his autobiography, Karma,  ‘Trust me, anyone who was fat last year and is now skinny is on the wonder drug’. With so many people starting to use Ozempic and vouching for its efficiency, it perpetuates an unhealthy mindset. Those who are not thin feel pressured to take the drug or risk being judged by society for not doing so. Heavier individuals frequently encounter well-meaning suggestions like 'You should try Ozempic!' from friends and family, which only reinforces the belief that being bigger is not acceptable. The situation is reminiscent of the rise in the popularity of plastic surgery and Botox, where the pursuit of an “ideal” and symmetrical appearance threatens to erode our individuality.   However, the impact of Ozempic on the body positivity movement presents a complex, individualistic scenario. Influencers who have built their following on promoting body positivity may feel conflicted, fearing that taking Ozempic, even for health reasons, could be seen as a betrayal of their plus-size community . It's important to recognise that for many people with health problems in the context of obesity, using Ozempic isn’t solely about appearance; opting for it can be a valid choice to improve one’s health.   Maintaining a balanced perspective is crucial, where health and self-acceptance are intertwined. While Ozempic may offer benefits for weight management and health enhancement in people who are at health risk, its use should be guided by medical considerations, free from societal pressures or expectations. Ultimately, the body positivity movement encourages individuals to feel comfortable and confident in their own skin. If Ozempic becomes widely adopted among those considered healthy by medical standards, there is a risk of undermining the movement's core message of celebrating diversity - as well as exposing healthy people to the risks associated with a powerful medication.   If you would like to read more about Ozempic, head to Part 2, where I discuss the effects that the rising popularity of this drug has on people with eating disorders.

It’s no secret that becoming an Olympian is one of the most impressive athletic achievements; one that many can only dream of. Becoming the biggest of them all, a true G.O.A.T. (The Greatest of All Time), is not for the faint of heart.   When it comes to sporting success stories, we immediately think of legendary athletes such as Simone Biles, Naomi Osaka, or Michael Phelps. And yet, whilst being incredibly different, these elite competitors all have one thing in common: they have all openly spoken about the mental health of athletes.   Turns out, winning medals is about so much more than just physical fitness, it’s all about a specific mindset, a winning attitude, a strong sense of resilience, and a healthy mind. T he importance of mental health for Olympic athletes cannot be overstated. Just as there is a crucial mind-body connection in achieving peak physical performance, taking care of one's mental health is equally vital. Elite athletes have to prioritise self-care and allow themselves time to recover mentally, just as they would for a physical injury, even if that means taking time off from their beloved sport - read more on this in our 'And Still, She Rose' article on Simone Biles . And, unfortunately, whilst the public often only sees the moments of excellence and victory, many athletes have spoken about the private anguish taking place behind the scenes. So as a reader, as a spectator, as a coach, or as a sponsor, it's essential to remember that athletes are humans first , with emotions and lives beyond their sport. On a big scale, the Olympics, and sports in general, can serve as a powerful platform for broader societal conversations, including the importance of mental health. Notably, some of the greatest athletes, like Phelps, have openly discussed the "Olympic come down," also known as post-Olympic depression, highlighting that the struggle with mental health issues is a common experience among many successful and elite athletes. Psychiatrist Alan Currie, a member of the International Olympic Committee’s (IOC) mental health working group, praised the open-conversation approach in Paris , noting that some athletes have become active ambassadors. For example, Olympic athlete Holly Bradshaw described also experiencing post-Olympic blues, leading her to contribute her experience to academic research where 14 anonymous athletes discussed feeling like "medal-winning machines" and struggling after the Games. Based on some of these conversations, the IOC had already started to recognise the need for support ahead of the games in Tokyo; but with the games now in full swing, the Paris 2024 Olympics have proven to be the most dedicated and supportive games yet in prioritising athlete’s mental health, with new and updated measures continuously being put in place. The committee has used this year’s competition to launch an athlete-focused mindfulness program that provides 2,000 athletes with acc ess to the Calm app , as part of an effort to support mental health and well-being. A mental fitness helpline is currently also available for all teams, 24/7. Additionally, athletes competing in Paris, and for four years afterwards, can access mental health and well-being support in their home countries in over 70 langu ages. The Olympic Village has also increased its mental-health-focused amenities, with a designated "mentally fit zone" for mental decompression, alongside a gym to provide a quiet space away from the noise of the competition. New technology is also being used as a support tool . AI was introduced to detect and remove abusive content on social media. The content is identified and forwarded for human review, with any confirmed abusive comments being removed from the platform before the person it targets can see it. Any criminal content is then reported to law enforcement. Kirsty Burrows , head of the Safe Sport unit at the IOC , emphasises the importance of these supportive environments for athletes, saying that “they should feel that there are support systems around them. They should feel if they have a concern around menta l health or well-being or any areas, that they are able to speak up and they’re able to seek support. And there are systems in place that help them to do that”. As part of the IOC’s efforts to recognise that athletes’ mental health needs are as important for their performance and well-being as their physical health needs, and that good mental health means much more than the absence of a mental health symptom or disorder, they created the ‘ The Mental Health Action Plan’ with key targets for 2026. This new action plan, guided by principles of human rights, equity, evidence-based practice, and collaboration, outlines the IOC's strategy for promoting mental well-being across its four areas of responsibility: the IOC as an organisation, as the owner of the Olympic Games, as the leader of the Olympic Movement, and in society. By 2026, the plan aims to achieve key objectives in five focus areas: Culture and leadership:  Championing policies that recognise the importance of mental health. Measurement and research:  Enhancing understanding of mental health in elite athletes and under-researched groups, with a focus on cross-cultural differences. Reduce prevalence and improve well-being:  Developing tools and initiatives to improve mental health literacy, reduce stigma, and address sport-specific stressors. Improve care:  Creating psychologically safe environments and facilitating access to necessary support. Improve access to sport:  Promoting the mental health benefits of sports, particularly in resource-limited settings, through Olympism365 .   By embracing the importance of mental health and creating a supportive environment, we can empower athletes to reach their fullest potential, both on and off the field. Together, let's champion a culture where every athlete can shine, both in moments of victory and in their journey of growth and well-being. Now is the time to go for gold — not just in performance, but in creating a world where mental health is as valued as physical prowess. Let's support our athletes in their pursuit of excellence, ensuring they have the tools and support they need to thrive. The future of sport is bright and, with a holistic approach to well-being, the sky's the limit.

Trigger warning: This article contains mentions of sexual abuse which some readers may find distressing. You’d be hard-pressed to find someone who hasn’t heard the name Simone Biles . Often used interchangeably with ‘GOAT’ and ‘one of one’, the Olympic Medallist and Gymnastic World Champion is a household name, and honestly, deservedly so. I, like many, am completely in awe of her. In gymnastics, she’s in a league of her own. Performing skills at difficulty levels so high that many have argued she’s restricted by the sports’ scoring systems, her talent and strength have pushed boundaries beyond what we thought possible. But the accolades aren’t just limited to her sportsmanship; Simone Biles has, whether intentionally or not, become a role model for looking after one’s mental health. During the postponed 2021 Tokyo Olympics, the world watched on as Simone’s performance was affected by the ‘twisties’ ( a psychological phenomenon where gymnasts lose spatial awareness in the air ). There was a huge amount of backlash following her decision to withdraw from events, with little consideration for the human behind the athlete. Three years later, we have just witnessed history. Simone Biles returned with an incredible comeback at the 2024 Paris Olympic Games earning her gold medals in the women’s team final, individual women’s all-around, and women's vault, and a silver medal in the women's floor exercise. While it’s great to watch athletes like Biles build their medal collections, it’s even better to watch them succeed after difficult times. And this may be the biggest win Biles is taking home from Paris. Fighting hate with openness When Simone Biles withdrew from events at the Tokyo Olympics, USA Gymnastics released a statement about a ‘medical issue’. Shortly after, Biles herself revealed it was due to her mental health rather than a physical injury. While many could see she was going through something difficult, she faced a storm of criticism , with disgruntled haters fixed on presumptions that she would bring back the gold for Team USA following her breakout success in Rio 2016. Even a US government official compared her withdrawal to a gymnast in the 1996 Olympics, Kerri Strug, who pulled off a winning vault for her team despite a serious ankle injury . “Contrast this with our selfish, childish national embarrassment, Simone Biles” they proclaimed in a now-deleted social media post. They have since apologised for the post . As often is the case with mental health, when you can’t see it, and you can’t see a bandage, or blood, or a scar, people struggle to understand it. In reality, she was brave and sensible. By stepping back, Biles had valiantly put herself first and avoided physical injury at the hands of the twisties which was caused by psychological factors. It wasn’t until more recently that Biles went into more detail about what she was experiencing during those Games. Speaking to Alex Cooper, host of the ‘Call Her Daddy’ podcast , Biles reflected on how athletes tend to be good at suppressing things but that it can’t be maintained. “That’s what you saw at the Olympics”, she tells Cooper, “a big old spill”. A few years ago, news broke of the biggest sexual abuse scandal in sporting history, in which Larry Nassar, a national team doctor for USA Gymnastics, was a central figure. Larry Nassar sexually abused more than 265 women under the guise of ‘medical treatment’ , Simone being one of the hundreds of survivors. The trauma these young women experienced is unthinkable and many have spoken out about the effects it has left them with; Biles spoke candidly on the podcast on how for her, it has led to years of depression and anxiety. While she says she has good days and bad days and therapy to support her, the trauma, while not something that should define her, is something she will hold for life – the twisties in Tokyo were an example of how that can manifest. Shortly after the Tokyo Olympics, Biles debuted a new tattoo, reading “And still I rise”, a nod to the illustrious poem by Maya Angelou. “I feel like that’s kind of the epitome of my career and life story 'cause I always rise to the occasion, and even after all of the traumas and the downfalls, I’ve always risen” says Biles , and few can argue with that as we’ve watched her return to the Olympic podium in Paris. The weight of the world on her shoulders During the recent team qualifiers and finals, the first coverage of 2024 Olympic gymnastics, it was clear that Simone was the one to watch. Quite literally. Even watching coverage in the UK, I couldn’t help but notice that Biles was the only gymnast to have all skills (vault, floor, beam, and bars) televised during these group rounds. British commentators even shared concern for the athlete, noticing at least 15 cameras on her at all times and hoping they would grant her space moving forward - something which doesn't seem to have happened. Biles has even opened up on social media about the anxiety she's been experiencing in the Olympic Village this time, with even her fellow athletes giving her a lot of overwhelming attention. All eyes have been on her since she announced her ambitions for a comeback. But with that, comes great expectations. A recent Netflix docuseries ‘Simone Biles Rising’ showed her in the run-up to this year’s Olympics. “Have you guys ever seen that statue, with the man holding, like, that thing on his back? Do you know what I’m talking about?” Biles asks the crew behind the cameras, “Like, yes!” she says mimicking the stance, “That’s what the expectations felt like.” That guy holding that thing on his back is Atlas, the statue of an Ancient Greek Titan, the thing on his back, the heavens. The comparison is clear – the pressure must feel as though the weight of the world is on her shoulders and it must be happening again. Both Biles and Atlas are similar in strength and power, but perhaps the similarities end there. Atlas, as depicted at the Rockefeller Center, is made of bronze after all, and we know Biles can make gold. Throughout these games, like many, I have felt concerned about the pressure on her. She’s under the spotlight to an extent many of us can scarcely imagine. The pressure of competitive sports can be enough with external pressures from peers and fans, the need to continually develop, to avoid injury, and for Biles, to stay at the top while the world is watching. Some of her critics have recently apologised after seeing what the break has allowed her to achieve. The sporting success is one thing, but Biles has undeniably demonstrated that she made the right move. By taking a break she has been able to make a triumphant comeback in what some are labelling her ‘redemption tour’. She’s shown us all that she’s still at the top of her game, possibly even as a stronger athlete, and person. Watching Simone Biles perform is something otherworldly. She is of such insurmountable talent it feels like an honour to witness her success in real-time. But beyond the sport, it is special to watch her break down the boundaries – to talk about the struggles, show an openness and vulnerability that lets you realise that it’s ok to not always be at your best, but also, that taking a break for your mental health can sometimes be the best thing you can do. Her openness is something to applaud as she’s paving the way for others to prioritise their own mental health, establishing herself as a role model, and not just in her sport. "You may write me down in history With your bitter, twisted lies, You may trod me in the very dirt But still, like dust, I'll rise" — Maya Angelou And she really did rise.

Even if you aren’t picking up a physical paper and flicking through its pages, chances are that on occasion you have been scrolling down your Twitter feed and have come across a BBC news article that caught your attention. Most of us will not doubt what we read in the headlines: newspapers are one of the most influential sources of information available to us, so why wouldn’t we believe them. For example, how many times have you read about a natural disaster in the news and thought to yourself: Surely the earthquake wasn’t really 4.3 in magnitude? Did 600 people actually have to evacuate their homes when the flood hit? It was probably less. Never. Newspapers tell us what’s going on in the world, don’t they? Despite this, when it comes to certain topics, we are unknowingly presented with biased portrayals of reality. Sadly, mental health is one of these topics. Perhaps the most famous recent example of an infuriating headline is ‘1200 killed by mental health patients’ printed in The Sun in 2013. Many newspapers, and charities involved in mental health, deemed it ‘ irresponsible and wrong ’. This is just one of countless cases of damaging ways that mental health is presented to us; fearmongering plastered across the front pages of the most widely read papers and websites. It is important to note that I am not saying that journalists lie — rather, they sometimes present the evidence in ways that depict mental health in a negative light. This only serves to exacerbate the stigma surrounding mental health. Because mental health patients are continuously linked with crime and violence, we are influenced to believe that, essentially, they all are ‘dangerous criminals who threaten our safety’. This could not be further from the truth. Just as the crimes of one person cannot condemn the rest of us, people with mental illness are no different to anyone else; ‘they’ are not all criminals. In fact, in stark contrast with media stories, crimes by people with mental illness are incredibly rare occurrences, and also massively outweighed by the number of crimes committed by offenders who do not suffer with any mental health disorders. A fact report from the Time-To-Change charity broke down the statistics for 2009. The whole population of England and Wales is 43 million people, and when considering adult mental health rates, it can be estimated that around 7 million experience mental health difficulties. That year, around 50 cases of homicide involving a person with a known mental health disorder at the time were reported. So, the other six million nine hundred ninety-nine thousand nine hundred and fifty individuals are not murderers, andnot dangerous at all. In general, there are around 1.5 homicide convictions per 100000 population in England and Wales. Of these, homicide convictions, only 1 in 20 are related to the presence of a mental disorder. In order to prevent one stranger homicide, 35 000 patients with schizophrenia judged to be at high risk of violence would need to be detained . Thus, even if the risk of violence in mental illness is reduced, 96% of the violence which currently occurs would remain as it is, because it occurs at the hands of the ‘general public’ . Mental health is not a top contributor to violence or crime. In fact, the truth is that mental illness is more likely to place a person to be at risk of being as a victim, rather than a perpetuator, of crime. People with a mental disorder are 5 times more likely to become the victim of crimes, such as violent assault, compared to everyone else. Statistics like such are harrowing in contrast to what we are so wrongly led to believe. Because of this negative labelling, the media tends to group those with mental health difficulties as ‘others’, separate from ‘the rest of us,’ and thus connections to crime and violence due to a single case are subsequently and unfairly reflected on this whole ‘group’. A study published in 2017 , comparing media coverage of mental vs physical health, revealed that over half of articles addressing mental health were written in a ‘negative tone’. Furthermore, a massive 18.5% linked mental health and violence, compared with a minute 0.3% of articles linking physical health and violence… need I say more? Going back to the article published in The Sun, the article claimed to reveal ‘disturbing failings in Britain’s mental health system’, allowing mental health patients to be a danger to the general public. INCORRECT. The number presented, ‘1200,’ is correct. But, The Sun missed that this figure is not the number of people killed by mental health patients (that is, people under the care of psychiatric services). Rather, as highlighted by Channel 4, this is the number of people killed by individuals suffering from mental illness who were both treated or untreated  — a significant difference. Labelling the entire group as mental health ‘patients’, and suggesting that services are not a helpful preventative measure, could lead people to believe that psychiatric treatments do not work — that, as soon as there is a mental health problem, treatment or no treatment, there is danger. However, scientific research exploring mental health and crime, specifically homicide rates, demonstrate that rates of homicide decrease with psychiatric interventions, and so it is important to clarify this. Adding to the negative spin, The Sun article also missed that the original report actually highlighted a significant decrease in the number of mental health-related crimes over time: that this figure was the lowest it had been in 20 years — so, actually a positive message about mental health which had not been put across. While the newspapers are not solely responsible for the stigma, media has exacerbated the issue significantly, and the consequences need to be recognised. The danger of stigma is more concerning than maybe initially perceived. Continually facing the stigma around mental illness can worsen mental health, prevent seeking treatment, lead to isolation and unemployment, and can essentially trap individuals in a cycle of illness . The media may not have necessarily created the issue, but it continues, and will continue, to magnify the issue, unless there is a big change. Words have power, and so do the media. The words written in the newspapers should be used to raise awareness and to debunk the stigma that has somehow led us to believe that people who suffer from mental health difficulties are criminals, and that they are any different to the rest of us. Just as we have seen an overall increase in general reports on mental illness (which is a good thing), we need to see a decrease in the proportion of these written with a negative tint. We need to see less bias toward linking crime with mental illness, and more accounts from the people who actually live with mental illness. So, give us the facts, the actual truth. Not all mental health patients are criminals, so why should they be made to feel as though they are?

Emma Watson in Conversation with Dr Denis Mukwege, presented by The New York Times and how to: Academy Trigger warning — This blog addresses sexual violence with extreme violence. This article was co-written by Ellen Lambert. About two weeks ago I attended an event which truly had a profound impact on my life. Myself and my colleague, Ellen, attended an event entitled ‘Emma Watson in Conversation with Dr Denis Mukwege,’ part of a series called ‘How to Understand our Times,’ presented in collaboration between the New York Times and how to: Academy . The event was an opportunity to hear Emma and Denis discuss the horrific crimes experienced by thousands of women and girls, his philanthropic work in response, and how we can create a safer and fairer future for women and girls. It was a chance to hear how a medical doctor had recognised not only the physical, but also the mental injury sustained in the trauma, and how this lead to a complete change in the treatment of survivors. As a young woman myself, living and finding her feet in a time where there is a heavy emphasis on gender equality and movements including Time’s Up and Me Too, I was somewhat aware of the topics that were going to be addressed. However, there in that room, I could have cried. I could have cried at the things we were told about the violent exploitation and sexual abuse experienced by women and even children. I could have cried at how inspired I felt to be in the presence of two such influential figures. I was touched way more than I expected to be. Despite being best known by literally everyone for her portrayal of popular Harry Potter character Hermione Granger, Emma Watson has quickly become renowned for her encouraging work as a women’s rights advocate. At just 29 years old, Watson has used her platform to inform the masses on gender equality issues. She has already created momentum, with her role as a United Nations Goodwill Ambassador and the launch of global ‘ HeForShe ’ campaign, and shows no signs of slowing down. She inspired many of us in our youth to be strong and independent females, just like Hermione, and she continues to do so now —  minus the wand . Dr Denis Mukwege is a world-renowned gynaecologist and human rights activist. In 1999, Dr Mukwege founded the Panzi hospital in the Democratic Republic of Congo (DRC). He spoke emotively, of the first time a patient came for treatment after being violently raped, and soon after he saw an influx of similar cases. It had soon become a far wider issue in his region, and he knew that something had to be done. When treating them medically, he began to really talk to them, understanding that often he was the only person there to support these survivors emotionally. From this point on he developed the One-Stop Centre (OSC) model, a holistic approach to treating the survivors of such violent sexual abuse. I found it very hard to hear details of the rape and extreme violence, and generally the atrocities inflicted on the women and girls, that we heard Dr Mukwege talk about. While these crimes are always abhorrent, hearing that these actions were also inflicted on children under the age of five was a particularly hard pill to swallow. However, it is important that these stories are told so that we can make a change and end this unnecessary torture and suffering. The OSC model was essentially why I was there and why I am writing this piece on a mental health platform. Survivors of traumatic events, such as the sexual abuse and extreme violence spoken about here, inevitably face psychological distress after the event. However, what is really significant about this event, and what I want to emphasise , is that Dr Mukwege was the first medical doctor to really address these psychological issues as part of his patients’ care. And because this one extremely passionate man took the time to listen, a holistic approach flourished and is now a lifeline for thousands and thousands of women subjected to such atrocities. Dr Mukwege was appropriately described as “the closest you will get to meeting a Saint,” and after the event I can’t help but agree . My friend and colleague, Ellen Lambert , has helped me to summarise the OSC pillars. She was also deeply moved by the event and inspired by Denis’ dedication to ensuring women’s rights. The model, the One-Stop Centre (OSC) is an innovative, holistic, person-centred approach . The model was developed at Panzi hospital after years of treating girls and women who have experienced these atrocities, and it is now being implemented at other institutions. “OSC gives more than holistic individual care; it provides a platform for achieving a healthy lifestyle at the micro- (the person) and meso- (local society) levels and, if conscientiously and systematically implicated in all health care structures facilitates achievement of the right to health for all on the macro (national) level” ( Mukwege & Berg, 2016 ). The model is very much a collaborative plan between the survivor and specialists and is aimed at covering all areas of recovery. Treatment plans are based on that foundation of empowering the survivor; all aspects of treatment are based on emphasising the ‘dignified individual with value,’ and supporting all aspects needed to understand the trauma. Medical care begins with a consultation from a physician, where they are medically examined so that a plan can be put into place for further treatment. Tests for things such as HIV, pregnancy, syphilis, secondary consequences of injury are performed. Really making sure to treat and test for all of the effects of the crime and where needed, referring to specialists. What is unique about the treatment is that the survivors are treated depending on the amount of time that has passed since the sexual violence occurred. For example, when a lot of time has passed since the trauma, medical treatment becomes far more complex and the psychological effects become a lot more important . Dr Mukwege’s role began as a medical doctor, mainly performing surgeries on the physical injuries endured; but what struck me the most was when Dr Mukwege spoke of how these survivors would wake up after their surgeries and would immediately ask about their families. This selfless-ness is what gave him the strength to continue his work, however emotionally draining it may be. This is something that really hit us, taking on other people’s issues is a selfless act in itself, yet it is the selflessness of others that helps him in his mission. When he started treating girls and women subjected to this sexual abuse with extreme violence, Dr Mukwege soon realised that it wasn’t just the physical consequence that needed to be addressed, it was also the mental pain. This is when he created the second pillar, psychological therapy . Similarly to the start of medical care, psychological supports begins with an evaluation with a psychologist, so that a care plan can be designed, unique to the individual and their needs. As well as talking therapy as a means of emotional support, a large part of this pillar is the additional activities provided. Drama and music therapy is offered, to promote processing of experiences in different ways and to support relief. With the nature of the crimes experienced, it is not uncommon for the survivors to experience depression, anxiety, post-traumatic stress disorder and other psychiatric disorders. These women and girls are referred to specialist treatment. What is also prominent in this pillar is that where necessary, support and counselling can also be given to the survivor’s families. For example, relatives may need support to address their anger over the situation or feelings of guilt, and often support is given to prevent marginalising harm of the survivor. At one stage, Dr Mukwege was performing up to 10 surgeries a day, yet still found the time to talk and listen to these survivors. Despite this, and still doing around 10 surgeries in an average week now, Dr Mukwege maintains that these are the easier days, in comparison to the days he spends providing psychological support. When Watson asked how he approaches not having all of the answers for his patients, Dr Mukwege regarded that these are the hard moments, having someone in front of you, crying alone with no support. He loses sleep because he cannot solve all of their problems. But the one thing Dr Mukwege said he could do was to give love. Everyone needs love and he has seen first-hand how when they have love, their whole lives can change. “Everyone can give something if you think of the person in front of you. You might not be able to help physically or surgically, but you can help if you are willing to give love.” This quote will stay with both of us for a very long time. And we can’t help but feel how lucky it is that Dr Mukwege is there and of support in the DRC. Socioeconomic support is perhaps one of the more surprising elements of the model. To most of us the medical care seems obvious, the psychological care understandable, but the socioeconomic support really demonstrates how above and beyond this individual was willing to go to help these women and girls regain their lives. For a lot of girls and women in the DRC, their trauma can lead to rejection from their families and society. Survivors after rape will often live with a label of what happened to them. While it cannot change what has happened, and the survivor will never forget, this pillar can help them to regain strength and re-establish their value as a woman and in her society. Occupational therapy activities such as basket making, flower arranging, sewing and knitting are provided. Developing such skills and socioeconomic actions can redevelop social networks. Mukwege fondly told us a story of a few women who had become soap-makers, they had soon grown their business and were providing for their villages, proudly returning to the hospital to provide him with their soap which had transformed their lives. Such programmes support a survivor’s reintegration into society, giving them skills whereby they have something to contribute. When survivors are very young, Panzi developed a programme to support sending these girls to school. Dr Mukwege noted how important this programme is, especially as many are subjected to rejection. The schooling helps them to grow strong, but also strong economically. The schooling programme has so far successfully sent 5000+ girls to school. With regards to community reintegration , between 40 and 60% of women who seek treatment at the Panzi Hospital are unable to return to their communities once they are discharged, as briefly mentioned above. This can be due to the extent of their injuries or because of ongoing violence in their villages. Most often though, it is because of the deeply engrained stigma that surrounds sexual violence in the Congo. A double tragedy occurs. After being raped, many women are mocked, disowned and expelled from their homes by their husbands and neighbours because they are believed to be unfaithful and to bring misfortune. It is reported that some people believe that a mother’s milk is poisoned forever after they are raped. This abandonment makes victims of sexual violence extremely vulnerable physically, psychologically and financially, especially if they are left to raise their children alone without any support from their husbands. Acknowledging the vital importance of socio-economic reintegration for survivors, Dr Mukwege co-founded an aftercare centre for women unable to return to their homes, fittingly named the “City of Joy”. A new Netflix documentary grants us entry into the “city” which first opened in 2011 and has since enabled over 1200 women to continue their healing and plan for a stable future. “ Each day at the City of Joy is a lesson ”, as their website says. At the city of joy, women and girls receive housing, meals, and valuable life skills. Specialist trainers equip the women with skills in self-defence, farming, knitting, sewing, massage, culinary arts, soap making, and theatre. These are skills that can be applied to future ventures but also act as a form of therapy. Women attend lessons in English and Mathematics and are given microloans to support them in launching micro-enterprises. They are also provided with a comprehensive education in sexuality and the skills and confidence to demand their rights if and when they are violated. Women officially graduate from the city after 6–12 months, and as graduates each individual is expected to use their newly acquired skills to become a leader in their community and to establish support groups for other young women. Again, from their website: “On their graduation the new wind has taken them fully alive to their communities to lead and tell other women to protect themselves.” The city of joy has been life-changing for many women. Detailed case studies demonstrate how these brave women have transformed themselves from victims of sexual violence to social workers, nurses, restaurant owners, farmers with new land, journalists, immigration workers, tailors, students, herbalists and much more. The fifth and final pillar of the OSC model refers to the enhancement of women’s rights through legal assistance and representation . Justice is not something that tends to be immediately demanded by victims of sexual violence. During his talk, Dr Mukwege explained that it is often after women recover physically, psychologically and economically, that they develop a courage and capacity to question why this happened to them, and to demand that their attackers receive punishment for their actions. The majority of attackers currently manage to escape any form of punishment, despite the fact that Congolese law upholds the equality of the sexes and mandates the elimination of discrimination against women . This sends a strong message to society that women, their thoughts, and their feelings are not important, and that sexual violence is acceptable within society. A message like this normalises violent behaviour and increases the chances of future attacks. To support women at this pivotal point in their healing journey, the Panzi foundation introduced a legal clinic to enable victims to develop and prepare a case against their attackers with the guidance of professional lawyers. The foundation provides full financial coverage for all legal proceedings. They pay for the judge, the lawyers of both the victim and the defence (as of course, everyone is deserving of a fair trial), and they even create “mobile courtrooms” for individuals living in remote parts of the country. Hundreds of cases have been filed each year since the legal clinic was introduced. A well-known trial led to a local politician and eleven co-members of his militia to be convicted and sentenced to life in prison for the “widespread, systematic rape” of over 40 girls aged between the ages of 6 months and 12 years. In terms of outreach, the clinic trains paralegals in the community to get the laws on the protection of women more widely known and understood through public awareness campaigns, and they regularly lobby the Congolese government to take the issue much more seriously (with success). In 2015, the Congo adopted a law regarding women’s rights and parity, and drafted a project to set up a fund for reparations to benefit the victims of sexual violence . When Dr Mukwege first opened the Panzi hospital he realised that rape was being used as a tactic of war. Sadly, the reality has still not changed today. The nature of these crimes occurring in the DCR are not just crimes directed at the individual, it is used as a tactic of creating terror. And it is not ok. The importance of the different pillars of the model is not only to heal the physical and emotional pain, but to also get justice, teach protection and to end silence. Dr Mukwege spoke passionately about how silence is a tool which helps rapists to continue these atrocities, because they know they can’t speak out; the most important thing is to break silence and use our voices as its own weapon against rape. It has got to a point where survivors feel guilty for what has happened to them, unintentionally protecting perpetrators and preventing help seeking. These pillars not only heal, but work against that. The OSC model serves to demonstrate the extraordinary work that started with one doctor so passionate and caring that he took the time to listen and be of emotional support to his patients. What Dr Mukwege has done is truly inspiring and has the potential to really transform the lives of survivors everywhere. Ellen and I both left the event feeling as though we need to do more and completely in awe of these two individuals who are doing all that they can to make a change and improve the lives of women everywhere. The talk concluded by Dr Mukwege providing the details of how to support the Panzi Foundation and it only felt right to include these details here. If you would like to contribute to this amazing cause, you can here . Header image source: Image from Emma Watson on Instagram

When we go to our GPs and are prescribed medication for the virus we’ve been suffering with, the stomach pains that have been stopping us for a bit too long, or those feelings of sadness and hopelessness that just won’t fade, we don’t tend to think about the process which made this medication available to us. But the truth is, for each antibiotic, pain killer or antidepressant we have access to, there is a lengthy and complex process which gets it there. Even after these drugs have been developed, they have to go through rigorous testing to ensure that they are absolutely safe for use and that they do what they intend to, before they can even be licensed and rolled out into everyday medical care. Here you can read more about how medicines become available in the UK specifically. The rigorous testing process mentioned is what we call a Clinical Trial . This field is particularly important to me as the essence of my work revolves around clinical trials. Back in 2015 during a bachelors degree in Psychology, I elected to complete an optional placement year where I successfully applied to join the Stress, Psychiatry and Immunology (SPI) Lab at King’s College London — this happens to be the team that brings you InSPIre the Mind ! After working with them for a year as an honorary research assistant, one bachelors degree and a masters degree later, I have found myself back in the same team… instead now as a Trial Manager of a clinical trial in depression! From my days as a placement student to now, clinical trials have become a major part of my career and I have now taken it a step further and alongside my work I am now studying for a Post Graduate Certificate in… you guessed it… clinical trials. So, what is a clinical trial? A clinical trial is a planned experiment typically assessing the effectiveness of a treatment or medical intervention. Such trials usually involve both patients and healthy people (who, in research, we refer to as healthy controls). The purpose of such trials is to better understand how to treat a particular illness and, when well-designed and run correctly, they are the best way of doing so. They provide invaluable information on both the safety and efficacy of the medical product in focus. They can change standard care and offer new hope. While, historically, this evaluation process has not been fail-proof, this is partly due to its reliance on the transparency of pharmaceutical companies when it comes to providing data regarding the safety and effectiveness of the drugs. In 2013, for example, there was a big scandal surrounding ‘ Tamiflu ’, which led to the unravelling of a far bigger issue. Press was flooded with the news that drug companies only seemed to be publishing 50% of their clinical trial results, holding back important information. In the case of Tamiflu, this had huge ramifications when the UK’s Department of Health spent £424 million stockpiling the drug but then had to write off a huge £74 million of that due to missing data as later findings concluded an inefficiency in preventing serious cases of flu. However, nowadays strict measures and mandatory registrations have been implemented, such as ClinicalTrials.gov , which mean that trials have to be registered as soon as they start, making it more difficult for results to be hidden. And Daniel (from the bible) and James (from the Royal Navy) were the first “trialists” The concept behind this research can be traced back hundreds of years. The typical protocol, consisting of both baseline (before intervention) and follow-up (after-intervention) observations compared between two groups of people, has been tracked all the way back to a 2nd Century biblical text , ‘The Book of Daniel’. In the ‘Book of Daniel’, Daniel of Judah compared two diets over a 10-day period and measured the outcome — something comparable to a clinical trial. So as we can see, the premise is nothing new. But as I recently learnt, the first actual clinical trial was performed in 1747 by James Lind , English Military Surgeon, and the ‘father of clinical trials.’ When at sea, Lind conducted an experiment that compared 6 different diets and the affect they had on scurvy in 12 sailors. But what was most significant about his experiment is that Lind was the first to use an actual control group — a group with which the treatment can be compared to assess the effect. In doing so, Lind found that patients eating citrus fruits, including oranges and lemons, recovered much faster than those eating other kinds of foods. Since Lind’s era things have only started to progress significantly in the last few decades. More recent advancements have led to the development of the most commonly-used format today — randomised controlled trials . Typically, a randomised controlled trial is where you have two arms: treatments vs control. Each participant (volunteer taking part) is randomly (that is, being by chance alone) allocated to treatment with the investigational medicine or a placebo. A placebo is like a ‘sugar pill’ with no active ingredients but is identical to the treatment, and is commonly used as a control in clinical trials. Today, there are an estimated 21 thousand recruiting clinical trials currently registered on ClinicalTrials.gov , investigating more that 2500 different conditions — each of these using the current model of clinical trials to investigate new treatments. Randomised controlled trials have been coined the ‘gold standard’ of clinical research and there is no doubt about their efficacy when it comes to testing a new treatment or intervention, but this does not mean that these study designs are perfect… There are many aspects which could, and should, be improved. So, what can we improve? The current model of clinical trials means that we are typically evaluating one treatment or drug at a time. When we consider the lengthy process it takes to develop the treatment, get ethical approval to run a trial, analyse the results and get the treatment licensed, this is a significant downfall. From the point of developing the drug to it being integrated into medical care, a considerable amount of time (and money) are spent, delaying making the most effective treatments available to patients. While timespan’s vary, going from initial drug development to licensing can take up to 10 to 15 years . Furthermore, with individual trials all typically evaluating one intervention each, you have a number of competing trials trying to recruit patients. As mentioned above, there are around 21 thousands trials currently ongoing — all of these studies are recruiting patients and/or healthy controls, and most of the time patients are not able to be enrolled in more than one trial at one time, meaning that it becomes a real competition to recruit patients to a trial within the desired time frame. It is also often reported that patients can find it difficult to navigate the complex clinical trial landscape. Where do we go from here? A new platform trial! On the 18th December 2019 a new project was announced — EU-PEARL (Patient-cEntric clinicAl tRial pLatforms). EU-PEARL is a unique partnership bringing together 36 world-leading institutions for the first time, with the purpose of creating a new and adaptive clinical trial platform . The partners include European hospitals, research centres, patient groups, non-profit product developers and pharmaceutical companies. This new project has the aim of shaping the future of drug development by changing the approach that we currently take to perform clinical trials with the creation of a platform trial . EU-PEARL is funded by and backed by the Innovative Medicines Initiative (IMI). I am delighted to be one of many researchers participating to this project, since my University, King’s College London , is an active partner and has a leadership role for depression. We are co-leading the Depression sector along with pharmaceutical company Janssen , global healthcare company NOVARTIS and coordinators, Vall d’Hebron Research Institute . But what is a platform trial? A platform trial is a clinical trial with a single master protocol (a guide that all studies have to strictly adhere to). All clinical trials have separate protocols, however, the difference here is one overarching one, meaning that multiple treatments can be investigated at the same time, and, if a drug is not working, it can be removed from the trial, making way for a new drug to be tested. Master protocols have been described as being a way of efficiently answering multiple questions in less time . In a typical clinical trial today, there are strict criteria which have to be met for including a patient, limitations on participating in further trials and restrictions on access to the drug following successful treatment in the trial. However, under this new approach, patients have the opportunity to try different drugs and access to the treatment will be made faster in the case of successful treatment. As you can see, this addresses the limitations and areas of improvement mentioned when discussing the current model of clinical trials. EU-PEARL aims to transform the current approach and will focus on the patient's interests while also addressing medical needs to more quickly and effectively develop novel treatment compounds and with fewer participants. The aim is to define a novel and enabling infrastructure where pharmaceutical companies and healthcare providers can work together to develop integrated research platforms as an achievable and realistic novel method to achieve better results in clinical studies. In addition, modern-day research is also changing in light of a rise in technological advancements. Technological innovation and big data are opening a whole new window of opportunity in clinical research — One that EU-PEARL is also embracing with the development of digital phenotyping tools to identify patients who may be eligible to be included in the platform trial! And all this will be done across four different diseases… EU-PEARL, with its intent on shaping the future of clinical trials to become more patient-friendly in both design and outcome, will do so focussing on four very different disorders: Major Depressive Disorder , Tuberculosis , Non-Alcoholic Steatohepatitis and Neurofibromatosis . These four disorders are very different in nature but are all currently facing a similar issue: getting new treatments made available to patients. EU-PEARL, with these four disorders, is just the beginning: it will provide a valuable framework with which we can design and execute integrated research platforms in other disease areas. With this new and unique collaboration between world-leading participants with different areas of expertise to bring together, we are hopeful that EU-PEARL can transform the future of clinical trial designs. With the new methods, tools and frameworks, it is our hope that trials will be better for patients and promote quicker access to new and novel medications. And maybe one day students attending my course on Clinical Trials will study EU-PEARL as the first platform trial, as I am today studying James Lind! DISCLAIMER: This article reflects the author’s view. Neither IMI nor the European Union, EFPIA, or any Associated Partners are responsible for any use that may be made of the information contained therein. The EU-Pearl Project has received funding from the Innovative Medicines Initiative 2 Joint Undertaking (JU) under grant agreement No 853966. The JU receives support from the European Union’s Horizon 2020 research and innovation programme and EFPIA and CHILDREN’S TUMOR FOUNDATION, GLOBAL ALLIANCE FOR TB DRUG DEVELOPMENT NON PROFIT ORGANISATION, SPRINGWORKS THERAPEUTICS INC. Header image source Maria Votyakova on Behance

Disclaimer: This blog is by no means an endorsement, nor is it advocating, illegal activities. It is purely a discussion about a trend of drug-use which is growing in popularity and could have potential implications for novel treatment approaches in mental health. It should be noticed that microdosing recreational drugs is, under law, a criminal activity. If you’re anything like me, you may have seen the concept of ‘ microdosing ’ popping up here, there and everywhere recently. Well, before our lives were rightly overtaken by news of COVID-19, that is. It’s a key theme running through six-time bestselling author Liane Moriaty’s hit, ‘ Nine Perfect Strangers ’. We are introduced to a group of strangers as they arrive at a wellness retreat hoping to resolve various invidual issues. But, there is a twist — the retreat turns out to be an unconventional one (spoiler alert — skip to the next paragraph if you’re planning on delving into this novel). As the transformational methods start to be questioned by the guests, we find out that they have been unknowingly drugged with microdoses of illegal substances as a form of ‘therapy’. It is also commonly mentioned as a new trend in Silicon Valley amongst technology circles. I’m sure we’ve all heard stories about the relationship between the valley and psychedelic drug use, but now there’s a different spin and that is to microdose these drugs. And it has gathered momentum in the media — only a few months ago my Grandad, who wonderfully points me in the direction of any psychology related articles he finds in the newspaper (thank you to him!), showed me an article from The Telegraph about a 34 year olds man and his personal experience . And it was at this point I thought to myself, yes, but what actuall y is microdosing? Being a clinical trial manager myself, I am well versed in knowing how drugs go through rigorous testing before they can be licensed and rolled out into clinical care (you can read more about this in my last blog ), however this phenomenon was something very new to me. I wanted to know more about the world of unregulated drug use in the mental health disorders I research, and how this drug use has gained so much popularity despite its lacking evidence. So, here is what I have learnt. Microdosing The phenomenon has been described as “consuming crumb-sized amounts of psychedelics — not to feel high but to feel more focused and creative and present”. Microdosing usually consists of taking small amounts of a psychedelic drug — usually one tenth to one twentieth of a standard recreational dose — it really is tiny doses in comparison to its full dose counterpart. The most frequent drugs to be microdosed are LSD, psilobilin, or ‘magic’ mushrooms; however, any drug with psychedelic properties are used, including cannabis, ayahuasca and ketamine, amongst others. Each drug can be microdosed for different effects to be achieved. An article in The Cut even provides a breakdown: microdosing LSD and mushrooms can result in a new found energy and focus; cannabis for pain, nausea and inflammation; heightened sensitivity and reduced boundaries can be the effects of ayahuasca; and microdoses of ketamine can reportedly be used for reducing stress and symptoms of depression. While the dose only stays in the body’s system for a couple of hours, reportedly the effects can last for some days. But what we know about this comes from individuals’ experiences only, and not everyone achieves these effects. There are only tiny amounts of actual scientific evidence when it comes to these tiny doses: it seems that in the case of microdosing, people have been taking things into their own hands. There is even a Reddit forum for microdosing users who compare notes and methods with some 24,000 users. So what do people use it for and why? I mentioned technology circles in Silicon Valley, and this is really where microdosing first gathered its popularity although, supposedly indigenous groups have been using the sub-perceptual doses for centuries . Young professionals working in the bustling hub of technology and innovation have insisted that taking these microdoses helps them perform at work by enhancing their creativity and focus. One individual describes the first time they experimented with microdosing after not having used psychedelics before: “I stared at a blank wall every now and then just to make sure I didn’t see any hallucinations, but there was nothing. Weirdly, it’s not until the next day, in retrospect where you look back, that you realise you handled things, or reacted to things differently. It’s so subtle it’s easy to miss. But it definitely worked”. Essentially, the act may provide some level of benefit, minus the hallucinogenic affect that psychedelics are known for. Creativity and focus aside, others have reported a significant benefit on their mood — many people microdose for mood balancing and management . In a piece on microdosing written in The Guardian , a woman spoke of how after taking 15 micrograms of an LSD tab (in comparison to a whole tab which is typically 100mg) she saw a positive change in her mental health — “It lifted me out of a pretty deep depression […] I’m able to be more mindful of my emotions. If I’m feeling sad, that’s ok. I don’t obsess anymore. I don’t dwell on it. I don’t get worked up about it.” Could there be implications for novel treatments for mental health? Microdosing for mental health With concerning proportions of those using antidepressant medication not finding any/significant improvement in their depressive treatment (‘treatment resistant’), it’s no wonder so many people are taking things into their own hands. An emerging body of research makes a case for using psychedelic drugs such as LSD and Psilobilin to treat mental disorders including depression. The effects of Psilobilin particularly hint at a potential benefit for treatment-resistant depressed patients and a first controlled trial of psychedelics using ayahuasca , in a controlled environment, indicates similar potential. And with evidence as such, which proposes the beneficial effect of full doses of psychedelic drugs in treating depression , it makes sense that people consider microdosing. In theory , could these small doses retain these beneficial effects without the consequence of distortions from psychedelic experiences? But when it comes to microdosing, a review published in 2019 identified only 4 scientific papers exploring the concept. Scientifically, this doesn’t amount to much evidence at all. These studies mainly recruited existing microdosing users to examine their experiences, and identified positive effects for depression and anxiety , and cognitive performance . When compared to those who were naive to the practice, microdosers reported much more improvement in their mood with depression symptoms lessening considerably. Despite showing benefit for mental health disorders such as depression , this research doesn’t seem to use clinical samples such as groups of people with a clinical diagnosis of depression yet. Is this the next step? It’s not just mood disorders which could be implicated here either. Psychedelic researcher from Imperial College London, Carhart-Harris, has suggested that people who suffer from mental health disorders such as obsessive compulsive disorder and addiction could benefit as small doses of drugs could help to interfere with the rigid patters of thinking and behaviour that are key in these disorders. Evidence is lacking because this is a relatively new phenomenon. Although research into the implications of microdosing on mental health is beginning to build momentum, what is missing is plain and simple scientific evidence from clinical trials, and this may largely due to the bureaucracy and regulations surrounding use of recreational drugs  — aka it is very hard to run a trial using something that is illegal. But, there is promise with one or two pre-registered trials on the horizon. What is next for microdosing? Until we know more, and by more, I mean a significant body of real hard-hitting scientific evidence, microdosing isn’t something that should be taken lightly, as the lack of evidence also means that we do not yet know what exactly microdosing does to the brain over time. While accounts of personal experience show that it may potentially have a positive effect in the short-term, we don’t know if there are detrimental effects to health and brain function later in life; not to mention that taking any regular doses of substances as such can lead to development of addiction . Until we can predict this better, it is better not to experiment yourself — not only is this unsafe, but also all the most commonly microdosed substances are illegal for use in the UK and in most other countries, and therefore any possession or use of these drugs is, by law, a criminal offence. However for now, what we know about microdosing is that we mostly don’t know. We are very much at the beginning of a new brink of research in mental health, and whether it’s psychedelics, microdosing, or another new treatment method, we can all hope that things will advance soon enough, so that we will have more effective treatments for those who need them.

Once upon a time, there was a girl who grew up to become a mental health researcher… No. Wait. Once upon a time? I’m not the Cinderella in this fairy tale… I am the girl who grew up to become a researcher though. I’ve been working in mental health for a number of years now and have written a number of blogs in this time. The first of which was all about stigma . Since then, I have written about an inspirational doctor, who transformed care for many . I have written more directly about my work with a blog on the future of clinical trials , and I have written about microdosing  — something which is very different to my own work but could have important implications for it. But my first — about stigma  — is the one I want to emphasise. It is my first one that hasn’t left me since, and most likely because of the prevalence of the issue. Stigma is one of the biggest barriers to seeking help for mental health. Mental health isn’t seen in the same light as physical. You hurt your knee and you go to the doctors, but it’s not often the same for our taking action for our mental health. I have grown up in a time where there has been a real focus on reducing this stigma, and these efforts are doing great things, but this isn’t the end of the story. There are further barriers. Throughout this time working in research, two things have become abundantly clear to me: Firstly, an incredibly large proportion of us will experience mental illness at some point in our lifetime. And secondly, mental health, has been a relatively underfunded sector in UK healthcare for a long time. When I say a long time, I don’t mean the last few years, I mean decades. But these seem like two contrasting issues to me — if we have a high demand for help and support and we are actively telling people to seek this, why isn’t the money pot being filled so that we can provide this? Mental health services are the real Cinderella of this story, with an awful lot of work and very little credit (in this case, financial credit). So, while stigma is just one barrier we are continuing to break down, I now find myself wondering about another: funding. More specifically I want to know why there appears to be such a difference between funding for mental and physical health. So I have decided to play detective and investigate the situation for myself. I have started by asking —  what is the current state of mental health funding in the UK? Is this truly a Cinderella story? The statistics on mental health are hard to avoid if you have access to the internet, a TV or newspaper. One in four of us will experience mental health problems  — that equates to a whopping 792 million of us worldwide . When it comes to our working lives, the cost of mental illness in England alone is estimated at £105 billion per year and as high as £99 billion per year worldwide . Depression is one of the leading causes of disability (my fellow depression researchers will know this sentence inside out and back to front). In 2013, approximately 8.2 million people in the UK experienced anxiety . 1 in 10 children between the ages of 5–16 will experience a mental illness. Up to 725,000 people in England currently have an eating disorder. And I could go on. The list of statistics is as endless as it is worrying, and it is clear that we need to provide support for a lot of people in need. Yet as it stands, the NHS does not currently seem to have enough funding to meet demand. Campaigns such as Time to Change , one of the UK’s largest mental health awareness campaigns, and more recent examples such as the Royal’s Heads Together campaign, are making impressive strides in shifting the narrative on mental health: breaking down stigma and making awareness in the general population all the more better. These campaigns demonstrate the value of asking for help and this is so important. Yet, alongside this, we are faced with another issue. More of us are coming forward for support, but despite our increasing demand, there doesn’t seem to be increasing funding for those services providing such support. In January 2018, The Guardian published an article entitled ‘Mental health still losing out in NHS funding, report finds’ . This article compared the disparity in the inflation of funding for NHS services. Between 2012–13, mental health services saw an increase in funding by around 5% whereas other services saw rises of up to 17%. From 2015–16, budgets for mental health rose only by 2% in comparison to a 6% increase for physical health services. The disparity is clear, and you can see why many people question the equality of money distribution, particularly given the prevalence of mental health problems experienced. An article by NHS providers in 2017 shows that children and young people’s services (CAHMS) are particularly struggling, with over 50% of services not being able to meet the ever-increasing demand. In comparison, services for cancer are meeting up to 95% of demand and reaching specific target deadlines. Don’t get me wrong this is wonderful news in cancer, but why can’t mental health services achieve the same standards? Before I continue to dive into the specifics of funding for mental health specifically, it is also important to note that the NHS is in a difficult position when it comes to funding in general. Sadly, there is not limitless money floating around and with the majority of NHS funding (approx. 99%) coming from general taxes and national insurance , money available closely reflects the highs and lows of the economy. Sorry for mentioning this during our current situation… But this does leave many sectors in need of a substantial cash injection so that NHS services are able to continue their incredible work providing the best care possible. The reality of funding is that growth in funding across the NHS has dramatically slowed since the 2008 recession . Funding is always going to be a difficult conversation and in reviewing the equality of funding pumped into mental health, I am not saying that any sectors are more or less deserving. If I had it my way, there would be limitless funding for all sectors but sadly this is not realistic. The reality is far more complex. What I am addressing here is the fact that mental health care has suffered disproportionately to its demand. In truth, funding hasn’t just been an issue for services — mental health research is less invested in, in comparison to its physical health counterparts. MQ Mental Health , a leading mental health research charity, recently reported that mental health research has been receiving 25 times less funding per person affected than conditions such as cancer. Research is funded in a number of ways but there is one particular example I would like to share as I feel it really emphasises the enormity of what I am trying to demonstrate: public donations for research into some physical illnesses is 900 times more than that donated to mental health research in the UK . We’re the Cinderella of research too. The day-to-day consequences of the lack of funding is clear and the main examples of this are demonstrated with waiting list times and lack of staffing. The state of waiting lists highlights this perfectly. A 2020 House of Commons Briefing Paper on mental health statistics for England reports that waiting times for NHS psychological therapy (IAPT — Improving Access to Psychological Therapies) can range from 4 days to 61. 61 days is a long time. Especially when you are desperate for that help. 61 days is a lot of time for things to worsen, things to go wrong. When you’re put on a waiting list, your life is put on hold, waiting for your chance for support. Waiting times don’t just affect the individual either, strain is placed on whole families and support systems and not to mention leaving staff at the services frustrated. During many occasions in my life, I have heard people rightly dismaying about the state of waiting times, but also incorrectly placing blame on the individual service providers. And I guess the most important thing I want to say is that no individuals, teams or services working in mental health want people to have to wait weeks, sometimes months, to get support. Actually, it’s the opposite. It is the financial system in place that fails these individuals, not the staff. And while much of the content in this blog has come from research online, my last point is one that comes from experience working as an Assistant Psychologist in a service for people with psychosis in 2018. It was a busy service in an area of London with some of the highest rates of Psychosis, the waiting list was out of our hands, but it was hard to see patients disheartened hearing how long they may have to wait. But when they did get to the top of the list and had therapy, it was lovely to hear when they were doing a lot better. Maybe this experience is why I am interested in the topic. Waiting list times are a direct consequence of a lack of resources — aka, a lack of staff. The staff who are employed still have to try and manage this high demand leaving many over-stretched and at risk of burnout. And it’s not just those providing the face-to-face support for patients, it has a knock-on effect on all, admin staff, housekeeping staff . All of these people trying to do amazing work are doing so under incredibly stressful conditions, yet still all doing their best. A report by the King’s Fund described how all of the mental health trusts assessed in an Analysis of Care Quality Commission reported that a lack of staffing is putting patients at increased risk. The importance and the drastic consequences that under-funding can, and is, having, is clear — without enough money, mental health services (or physical care sectors) cannot employ enough staff to provide the services needed, leaving many without help when needed and only causing further ill-health, with more intensive, and likely more expensive support needed for these individuals further down the line. But it is not all bad news: many years of campaigning for these inequalities has led to a change in direction. The main change being seen after the UK governments strife for a ‘parity of esteem,’ first mentioned in 2011. Parity of esteem in an approach to NHS treatment where a patients’ mental and physical health should be treated with equal importance. Research has shown us over and over that poor mental health can put you at higher risk of physical conditions, and/or poorer outcomes for these illnesses, not to mention mental health costs take up a fair amount of physical health spending and so this is a very good outlook to be pursuing. So how is this translating into funding? The strife to achieve parity led to the development of the ‘ Mental Health Investment Standard ’. This initiative ensures that Clinical Commissioning Groups (CCG’s) — who are responsible to distribution of NHS money within their local areas — must match increases in spending with increases in demand and add an additional percentage which reflects specific funding allocated for mental health. This is a strong step in insuring that mental health services aren’t ignored.But it is not all bad news: many years of campaigning for these inequalities has led to a change in direction. The main change being seen after the UK governments strife for a ‘parity of esteem,’ first mentioned in 2011. Parity of esteem in an approach to NHS treatment where a patients’ mental and physical health should be treated with equal importance. Research has shown us over and over that poor mental health can put you at higher risk of physical conditions, and/or poorer outcomes for these illnesses, not to mention mental health costs take up a fair amount of physical health spending and so this is a very good outlook to be pursuing. Further promise comes with the Governments ‘ Five Year Forward View For Mental Health ’. This came with changing attitudes in mental health and the reduction we have been seeing in stigma, and set out to invest an additional £1 billion by next year in order to improve mental health services . This should lead to an additional 1 million people receiving the correct care . The NHS have described this as ‘ a decisive and unprecedented step towards closing the treatment gap for mental health .’ Expansion to child and adolescent mental health specific services was a key objective of this, as well as perinatal mental health (pregnant women), and adult mental health in community and crisis care amongst others. Initiatives and increases like this are also more important now than ever before. A quick search on google will show you that the demand for mental health services is inevitably increasing and more substantially with COVID-19. In response, the Government’s Department of Health and Social Care have provided an additional £5 million of support offering grants to mental health projects particularly led by service users and small communities that will need the extra support now. So, while our attention the last few months has rightly focused on COVID-19, as we begin to make a move back to normal life, we can’t ignore that mental health services have been struggling for some time now. And with many of us having experienced the detriment of the virus and having to put life on hold in lock down, the pandemic has brought the importance of support for mental health to the surface, and shown yet again that not only are mental and physical health intertwined, they should be treated as equal. So, let’s really work for a focus on providing the right support for as many people as we can. It cannot be ignored. While it is probably unfair to just demand more money, knowing where the NHS budget comes from and how strapped for cash we are in general, what is significant is to adjust the balance. Considering the funding available, we need to do all we can to emphasise the importance of providing a fair share of what is available to mental health. Change is beginning to become evident, but we still have a long way to go and we can all but hope that these initial steps are the start of a new era for mental health. “Let’s make mental health part of the NHS and not the Cinderella service.” —  Susan Highton There’s still hope for a fairy tale ending.

Before we start to really dive in, I have a bit of a confession to make: I think I’m a perfectionist. Ok, well maybe it wasn’t the ground-breaking-jaw-dropping confession you were hoping for, but there is something about it that I consider ironic… I am also the type of person to say ‘there’s no such thing as perfect. ’ But what I wonder is, is it possible to be a perfectionist whilst also understanding that the concept is, for the most part, unattainable? Well, it seems so, and it may be this very reason that perfectionism isn’t quite what it seems. Perfectionism may be damaging for mental health. Now, I probably would have written this blog at some point anyway as it is something that genuinely sparks my interest as a mental health researcher with a background in psychology, but I think the COVID-19 pandemic has given me a bit of a shove towards it. For some reason, during this year particularly, I have become more aware of my perfectionist tendencies. I read a column from clinical psychologist Desiree Dickerson which hit the nail on the head for me — I think it is because this year has provided us with so many more reasons to worry about things that I realised my perfectionism shouldn't be one of them (that being, said she was working from home whilst looking after two young children so things sounded a bit more full-on for her than me!). For the most part, I think perfectionism has helped me with my education and career — I was motivated to work extremely hard because anything less wasn’t acceptable to me personally and was very critical of my work to always polish things and make it better. It also means I have good attention for detail (something that must help me writing these blogs and in my role as Co-Editor for InSPIre the Mind if nothing else, right?). But, that being said, I have recognised that it can provide me additional, and probably unnecessary, stress surrounding my work from time to time and this is what I have noticed particularly happening this year. Perfectionism is a personality trait; one where you tend to set extremely high, or ‘perfect,’ standards for yourself or others, and often struggle to accept anything less. Some people will experience perfectionism across their everyday lives while others may experience the tendencies relating to a specific aspect such as their appearance, school or work for example. Our culture has evolved and sculpted perfectionism to be seen in a positive light. Think of the go-to response in a job interview when asked about your biggest weaknesses, “I’m a bit of a perfectionist” — the reason being is it ticks the box as a weakness, but at a surface level it does have quite positive connotations: that you work hard and do things to the best of your ability. While the phenomenon is nothing short of new, it seems that it may be starting younger and younger and perfectionism is on the rise , particularly in Westernised civilisations. But the overall idea of perfectionism being something good is actually quite dangerous. According to Psychology Today , perfectionism appears to be on a scale, ranging from adaptive , a striving to achieve the best whilst not beating yourself up when you come up short of that, to maladaptive , a kind of perfectionism fuelled by excessive pressure and that tends to result in internal torment. The reality is, the existence of the latter half of the scale shows that it can actually be very dysfunctional, and we need to be aware of this with growing rates of us possessing the trait. The concept of ‘perfect’ is, at its core, largely unattainable and this is likely because it is a self-derived concept set by our own standards. In this sense, it’s almost like trying to mix oil and water — it’s fundamentally unmixable, due to molecular make-up, rather than any attempt you make. But knowing that perfect isn’t achievable doesn’t mean that you won’t push yourself to always do better. I wonder if this is why it can be maladaptive for some, but motivational to others? If you put too much pressure on yourself to try and achieve it, it is understandable that it can add additional stress to daily life and maybe it’s the response when falling short that comes into play too. One possibility is that maybe some perfectionists actually avoid (or fear in more extreme cases) failure more than they try to achieve perfection . For those who experience a more maladaptive type of perfectionism, the trait can often cause turmoil, anxiety and constant worry. And so, contrary to what is commonly perceived, it is not always the same as being competitive or a hard worker, there is a point where it becomes toxic — perfectionism can actually put people at higher risk of mental health difficulties. No matter where you look for information on the relationship between perfectionism and mental health, two names will flood your google search — Gordon Flett and Paul Hewitt. Flett and Hewitt have dubbed perfectionism as a ‘ hypercritical relationship with oneself. ’ The psychologists acknowledge that there are of course positive attributes which can be associated with the trait, but it is also the individual having a negative relationship with themselves, pre-occupation to achieve the best can trigger turmoil and a cycle of self-doubt. The pair, who are strong leaders in the field, performed a landmark study which demonstrated exactly why perfectionism can be simultaneously good and bad — it is actually a multidimensional concept, meaning that there are different variances of the trait. We most often know of perfectionism being about the self and having high standards for our own achievements (self-oriented) but perfectionism comes in other forms too, including other-oriented (expectations for the people around you), or socially prescribed (belief that others have standards for yourself and needing to meet this perception) — I didn’t realise until now, but this last one is definitely me. The study found that self-oriented perfectionism is highly associated with more common feelings of self-blame and criticism, along with experiencing extreme feelings of guilt, disappointment and anger. Socially-prescribed perfectionism on the other hand is highly associated with people fearing negative-evaluations from others and feeling anger. It is clear that perfectionism can have profound impact on our feelings, and Flett himself said : “A link between perfectionism and serious illness is not surprising given that unrelenting perfectionism can be a recipe for chronic stress.” The Motivation, Performance, and Wellbeing Research Group present the Perils of Perfectionism. It isn’t recognised as a mental illness in itself, but perfectionism and mental health seem to collide. Both adaptive and maladaptive forms of perfectionism have been linked to depression, anxiety, obsessive-compulsive disorder, personality disorders and eating disorders. Links with depression and anxiety are some of the most reported, although there is still a need for better understanding in research as to exactly how the relationship works. It has been suggested that when it comes to depression specifically, l iving in constant fear of making mistakes and having a cycle of self-criticism can lead to clinical depression and even suicidal thoughts  — from Gordon and Flett’s model, those who are self-oriented perfectionists are at the highest risk of this. In a similar way, perfectionism driven by a fear of not achieving, or disappointing others, can cause a lot of distress and can understandably lead to the experience of anxiety. Something possibly more surprising is the established link with eating disorders, but perfectionism is actually very common in people who experience anorexia and bulimia . It appears to have a role in the whole life cycle of the disorders , including impacting onset and recovery. Perfectionism grounded in appearance or weight can lead to obsessional thinking when it comes to diet, for example, constant striving for perfection may then act as fuel to the fire when it comes to controlling food intake as breaks in strict restrictions may be perceived as a failure. With perfectionism playing such an integral role, it is clear why reducing perfectionist tendencies can be a critical part of the treatment for eating disorders . Even in conditions beyond eating disorders, researchers have found that perfectionist tendencies may not just be a factor that puts you at risk, but it may be a maintaining factor too - something which essentially drives its continuation. A number of studies have also suggested that perfectionism can interfere in improvement, with possession of the trait tending to lower the effectiveness of psychological treatments such as cognitive behavioural therap y, a commonly used talking therapy for mental health. And if the links between perfectionistic tendencies and mental health were not enough, physical health can also be implicated by its perils. Studies have found that the stress triggered by toxic perfectionism can lead to experiences of fatigue, tension, headaches and insomnia . Flett described how the link between perfectionism and serious illness (mental and physical) is unsurprising considering “unrelenting perfectionism can be a recipe for chronic stress.” There have been many previous Inspire the Mind blogs on the impact of stress on our mental and physical health which you can read here . Personally, after doing this research I now consider myself to be very lucky. Yes, I do often stress more than I should thanks to my perfectionist tendencies, but there are so many people really suffering at the hands of perfectionism, both mentally and physically, and this is so much more than a bit of added stress. There is plenty of research out there on how we can break down the bridge between perfectionism and mental illness and this is what we should really focus on. Recent studies have suggested that self-compassion can moderate the link between perfectionism and depression for example, and that i nterventions based on self-compassion could be a useful way of reducing the toxic effects of the personality trait . So, to my fellow perfectionists — adaptive, maladaptive, socially-prescribed, socially-oriented: let’s try and be a little kinder to ourselves. I suppose next steps would be to identify factors responsible for the increase in perfectionism in Western civilisations. Research has shown that it affects younger generations especially hard with one study finding the percentage of college students with perfectionism tendencies rising by 33% between 1989 to 2016 , and socially-prescribed grew the most. Perhaps the rise and growing popularity of social media may be one of the reasons at play. Users are faced with perfectly (filtered) presented versions of people’s lives. Comparisons can leave users feeling inadequate of these standards, yet few are showing the real version of their lives. But, social media isn’t the only responsible party, there also seems to be at least s ome genetic component meaning that aspects of the trait may be inherited through family , however, it appears to be a complicated relationship with between 20–40% of perfectionism being inherited but varying considerably depending on both the dimension of perfectionism and on our gender. So there is also plenty of room for environmental influences to come into the scene. What we do know is that perfectionism isn’t as good as it is always perceived. While positive for some, in reality perfectionism can be very damaging for others and can result in a lot of stress. We need to be understanding of this and be aware of knocking down these perceptions, especially with rates on the rise. Let’s practice self-compassion and acknowledge that perfect isn’t real, it is normal to make mistakes, they won’t define you. Over the last couple of weeks, my perfectionism is something I have been more focussed on. Personally (and I can’t emphasise that enough — my perfectionism is minimal to the experience of others and I don’t want to undermine that), as someone who appears to be more concerned about failure and mistakes than about being ‘perfect,’ reminding myself of the reality of these situations has helped me to worry less: 9 times out of 10 a mistake I make means nothing in the grand scheme of things, and especially with everything going on in the world right now, so why should I worry so much. Self-compassion is something I will be working on a lot more from now on — as we all should. And so if you notice any mistakes in this blog, ignore them — I’m giving less energy to being a perfectionist!

I am from the UK, and this means that in just a few short weeks it will be exactly one year since our restrictions began with the first national lockdown. I don’t know about you, but this isn’t an anniversary I’ll be celebrating. Ever since this point, we have been living under such restrictions with little respite between. Lockdowns 1, 2 and 3 were sandwiched with tiers in the UK, meaning it has been a very long time since many of us have had even the slightest hint of normality. While I have only experienced lockdown here, much of the world’s population have been living under restrictions of varying degrees. Following the UK Prime Minister’s announcement last week, we may now be seeing the beginning to the end of our COVID-19 restrictions. This has come as welcome news to us all, but many are understandably airing on the side of caution. None of the past year has been easy, that is for certain, and many previous blogs on this platform have discussed the lockdown, from tips on how to staying sane at home and to sustain mental wellness , to an account of the dramatic situation during the lockdown in Italy , to lessons that the first lockdown taught us . But in this third, and hopefully final, lockdown, I have noticed that many, myself included, have been feeling the weight of lockdown 3 hard. Initially, we were encouraged by war-time rhetoric and many were inspired to start new hobbies, finding new ways to get creative to occupy time; now we are largely just trying to stay motivated. Even enthusiasm for connecting with friends on zoom has tapered off. Something about it has felt different and I think we have all collectively decided that the third time is in fact, not a charm. While we do our best to make it through these last few months, let’s look at why lockdown 3.0 has been so hard when in theory, it should now be our new normal. What is normal anyway? It is safe to say that despite us all following the same rules, we have largely all had very different experiences in lockdown. Some were furloughed and disappointed, some were furloughed and thrived, some started new business ventures, other businesses collapsed, new hobbies were discovered for some, whereas others continued to work and simply tried to stay afloat. Personally, I have worked throughout the pandemic. I am a mental health researcher (and writer and co-editor of ITM), my workload has remained, however, my new normal is working from home. The idea of something becoming somewhat of a ‘normality’ is what confuses me about the experience of lockdown 3.0. Last March saw our concept of normality turned upside down, flipped to the side and twisted in all directions. We might have thought that a year down the line, we would all be well practiced in a life in lockdown, but that doesn’t make it any easier. Then, what I want to know is why has lockdown 3.0 been so hard? There are many reasons suspected including disappointment during the promise of change beckoned by a new year, the time of year being more challenging for our mental health, but perhaps the most significant is our communal exhaustion. Pandemic Fatigue Simply put, we’re all tired. And being tired of it may just be why we have been finding things difficult — we’re experiencing what Public Health experts have termed Pandemic Fatigue. While the term hadn’t been coined this time last year, by January of this year it had been mentioned in over 200 million Google searches . Interestingly it has quite quickly become colloquial language both in academic and public spheres. The concept is defined as the state of being worn out or feeling overwhelmed by the restrictions and rules put into place as a result of a pandemic . Pandemic fatigue seems akin to burnout. Much like we can be burnt out from working hard for prolonged periods of time and the stress which comes with our occupational roles, we can experience similar feelings from the stress of following very strict restrictions for extended periods. Our constant state of high alert and compliance is exhausting and none of us are insusceptible to it. The longer we have had to comply, the harder it has become, which may explain why here, in lockdown 3.0, we have been feeling the weight particularly. The phenomenon has become just that — a phenomenon — so much so that the World Health Organisation (WHO) have even developed a document on how to ameliorate the effects of pandemic fatigue in order to reinvigorate populations to keep up adherence to restrictions . Pandemic fatigue hasn’t just been something we’ve been feeling, but something which may have actually affected the public’s ability to support the prevention of the virus. However, as WHO disclose, this growing mentality can be very damaging when all of us feel the affects of pandemic fatigue. What records do show, is that we’ve been experiencing pandemic fatigue long before the arrival of lockdown 3.0. While it is clear that it could have cumulative effects (the longer we experience restrictions, the more the effect had on us), I think it is safe to say that there are also other reasons why we have all been feeling the weight of this third, and hopefully final, lockdown. The timing, I strongly suspect, is one of these factors. Perhaps not surprisingly, this was the topic of a timely “ The Guardian Science Weekly Podcast” this week, featuring an interview with InSPIre the Mind editor, Carmine Pariante, on why are we all feeling burned out by the pandemic. Covid-19: why are we feeling burnt out? “ Ian Sample is joined again by Prof Carmine Pariante to discuss pandemic burnout and how to look after our mental health over the coming months” ‘2021 will be so much better’ Towards the end of 2020 there were plenty of ‘I can’t wait for 2020 to be over,’ and ‘2021 will be so much better’ ‘s vocalised. Lockdown 3.0 began right at the start of a new year — an occasion that usually brings with it the promise of change. It is a time of year where we reflect and set resolutions to improve things moving forward. This year, we all so desperately needed change and for life in 2021 to see the end of covid and lockdowns. Instead, we knew we were facing a second peak, we were grouped into various tiers and then placed in a third national lockdown just 4 days into 2021. Both optimism and motivation were squashed and instead of a fresh start we were hit with the realisation that 2021 may not be too different . Hopefully, our new plans for the end of restrictions six months in will begin to bring us new hope that 2021 can be salvaged. Summer of 2021 may have potential yet. January blues And it’s no coincidence I refer to summer —  lockdown 1.0 continued through the summer months of 2020. While most of us would have preferred to be on a beach or in a pub garden, I don’t think it is until now that we can fully appreciate that we had that good weather when we had not much else. January on the other hand brings shorter days, less sunlight and gloomier weather. While our restrictions in lockdown 3.0 have allowed us to go outside for fresh air and exercise, you had to be quite motivated to face the wind, rain and snow. We spent a lot less time enjoying the outside than we have previously been able to. I’m lucky enough to have a garden and spent much of my time in the first lockdown working outside whilst soaking up the rays. It is no wonder really that after spending a couple of months cooped up in my office and lacking the motivation to get outside and stretch my legs in the rain, I’ve found things harder. While the weather is a contributor, there are also other reasons that January may be harder. ‘January blues’ is a term for a reason — even without lockdown and announcements of daily death rates, it is a month that many find more difficult, mentally. It is the fallout of Christmas and the start of a new year which means that we’re typically getting back to work, suffering disproportionately financially, lacking motivation and feeling the pressure of change in the form of new years resolutions. Being in lockdown during the harder part of the year has been ill-timed. Those who usually struggle with the January blues or even seasonal affective disorder (aka SAD — a medical condition whereby mood is negatively affected by lack of daylight) will have experienced a particularly hard time. And many more of us may be able to relate, or at least empathise with this, somewhat more now. But as we arrive at the beginning of March, spring gets closer, the days get longer, and we start to see the sun more; we can start to appreciate that things will begin to get easier. A sense of normality has become a running theme in this blog and there is a final point that I would like to reflect on. As we approach June the 21st - the day the Government have set out to be the end of all restrictions - we should consider the enormity of change. There will be many who are exhilarated by the idea of reuniting with their friends, families and significant others in the pub for a drink, for a nice dinner or a big night out, but there will also be many who will find this quite daunting. Life in lockdown has been far from normal, but our pre-pandemic lives can seem like a distant memory — return to this can be a scary thought and may take some time to get used to. The term “ re-entry syndrome ” was introduced to discuss this fear when the first lockdown re-opened last year. Lockdown 3.0, in fact, the whole of this last year, has been really difficult for us all but what has been different this time, is that we have hope. Scientists around the world have been working tirelessly for a way out of this, and we are finally here, in the middle of a momentous vaccine roll-out which means that the end of our restrictions is in sight. Holding on to this hope I am sure will help us to get through these last few months of life in lockdown. But if lockdown 3.0 has left you feeling deflated, know you are not alone.

A conversation on women’s safety and the potential to make change At 9pm on the 3rd of March 2021, Sarah Everard left a friend’s house in South London and began to walk home. Sarah did everything that society has told us — women — to do: she left early, wore bright clothes, walked a well-lit route, and called her partner. But Sarah became the victim of something terrible. She didn’t make it home. A week on from her disappearance, we were heartbroken to hear that Sarah’s body had been found. A Metropolitan Police officer has been charged on suspicion of her kidnap and murder. Sarah Everard was a 33-year-old Marketing Executive living in London; she was a daughter, a partner, a friend. Her family have described her as someone ‘strong and principled and a shining example to all of us.’ This tragedy has caused an upsurge of anger and distress sparking societal conversations on women’s safety. The loss of Sarah is awful. It has understandably resonated with many women— a devastating reminder of our lack of safety. We all know the fear of walking alone at night, many of us have had experiences with harassment, maybe being followed, sadly, maybe worse. Sarah could have been any of us and this is haunting. She was just walking home. The last two weeks have been unsettling for women, it’s been a period of constant reminders of our own experiences, myself included. Not long ago I had a terrifying incident being followed, and these memories have come flooding back. I won’t go into details, but I do consider myself very lucky for how the situation ended. I share this to show that nearly all of us have a story to tell. For many, even as young women like me, there are countless experiences we can list. Some encounters aren’t always recognised as harassment, sexual or otherwise — actions such as catcalling, inappropriate remarks, even continued persistence for a number or a date despite a clear negative signal. It’s become a period of awareness for what we tolerate. But it’s also been a time of reflection among women — I’ve spoken to my mother about her experiences, she’s told me things that have happened to her mother, my grandmother. Through generations, nothing has changed. I sat down to talk to Professor Paola Dazzan, a woman, a psychiatrist, and academic at King’s College London. Paola and I can both relate to how many women are feeling currently. On realising we shared a joint passion for speaking up about this, it seemed like an opportunity for us, as women from different generations, to reflect on Sarah’s loss, the issue of women’s safety and what we, as a society, can do to make change. It seems to me that the loss of Sarah Everard has affected people more than any other case I can personally remember. So, I opened our conversation by asking Paola if she remembers any other cases which have had such an impact? Paola: As a woman I feel deeply touched by what has happened, and like you, I don’t remember a similar reaction to a dreadful event like this. In the past we have had terrible occurrences of girls, even younger than Sarah, who have unfortunately been assaulted and even killed, but for some reason this time seems to be somewhat different in how this has engaged the collective sense of fear and need for change. There must be aspects of what happened to Sarah that’s made us all identify with her. The fact that she was a 33-year-old woman, an adult, walking at 9pm, a normal time, and used the precautions all of us have learned while growing up. We’ve all identified with the ‘normality’ of what she was doing, she was just walking home. We all felt that ‘this could be me,’ my daughter, mother, or partner. And this is just one aspect. The other aspect is the fact that the person accused [ charged, not yet convicted ] of killing her is a police officer, and the meaning of this is very important. The person who has supposedly killed her is from a profession we see as protecting us — it has almost characterised this terrible event with a double layer of vulnerability. By chance, on the day Sarah’s body was discovered, a study by UN Women UK published results showing that 97% of women between the age of 18–24 have been sexually harassed. A further 80% of women of all ages reported experiencing harassment in public. What do you make of these statistics? Paola: To be honest, personally, they don’t surprise me — I would be in both categories. I remember being subject to catcalling in the streets at a very young age, just being 12, walking to school. I was also harassed on a bus as a University student. I think these experiences make us grow up with the sense that we just must get on with it and that it’s our responsibility, and ours only, to protect ourselves. As all women, I learned tactics — go for bright streets with other women and children walking by, for example. But I should not have to do this just because I am a woman: this is a restriction of my freedom. I think what is surprising is that we have known the statistics you mentioned for a long time. We have all reported it to our family members and friends, maybe teachers, who can offer individual support, but also tell us that this is ‘normal’, that we must accept it as just what happens in public. Sarah’s loss seems to have brought to the attention of men the extent to which women have to think about and fear their safety, what do you think could come from this? Paola: I think it could be what we have been hoping for a long time — that society, and men in particular, realise that it is not just women’s responsibility to remain safe when they are in public. What I hope is that will start shifting the way we, as a society, see where responsibility lies. I recently read a letter to the Guardian where a woman recalled being at an all-girls secondary school and given a specific lesson in how to avoid attack, yet, in an all-boys school, her brother wasn’t having similar lessons. It’s like society has accepted, until now, that the responsibility for women’s safety should lie with women. If this terrible event changes anything, hopefully it will be accepting responsibility of us all as a society. Men, women, young and old, teachers, politicians, or cultural figures — it is everyone’s responsibility, and this is the change that I hope will come. Currently, there still seems to be a culture of fear — in light of what happened, we are being reminded of the ways to keep ourselves safe. We’re sharing how to hold our keys in our fists, how to set up emergency SOS calls on our phones, and of course this is all vitally important, but is this narrative changing the issue? Paola: No in fact, you are right, it is not changing the issue, it is just reinforcing that it is our responsibility. I grew up as a woman, walking in the streets, often travelling abroad alone and of course I would do anything I can to protect my safety. However, just telling women that this is what they should do leaves all responsibility with us. But we should all worry about the harassment and the violence that is happening to other members of society, whether women, men or children. How do you think we change things moving forward? Could women’s safety benefit from keeping the momentum and having this at the forefront of societal conversation or do we need more? Paola: I think this is a very good start. It’s important that the emotion and the conversations of these days are something we build on. We must do this first out of respect for the victims. And then we should recognise this is a problem for society. Talking about it needs to be followed by action. There are things that we, as a society, can do moving forward. Firstly, there are actions men can take when they see a woman walking alone in the street, for example, making their presence obvious from a distance rather than walking silently behind, or crossing the street to keep distance. We also need to promote the involvement of councils in making sure our streets are safe. For example, in the 1980s, following a series of sexual assaults in Toronto (Canada), a Metropolitan Action Committee on Violence Against Women and Children was created to address public violence against women, with women and girls walking around public spaces in their neighbourhoods, often with a city official or police representative, to identify areas that felt unsafe. The findings were used to develop recommendations for the city. Councils and local police could identify existing areas which are particularly dangerous or need redesigning, or where more lighting may be needed for women coming home in the dark (which in the UK can be as early as 4pm in Winter). Incredibly, street lighting has been reduced during the recent austerity period in the UK, without considering the safety implications. Finally, I think that just looking at the statistics reporting the number of specific events (whether harassment or violence) can’t capture the fear and anxiety that all women constantly have when they feel potentially unsafe, like when simply walking home, like Sarah. The fear is not something that we’ll see measured by statistics, and yet is something that creates distress and, even worse, limits women’s freedom. Note: since our conversation we have heard news from Downing Street that ‘immediate steps’ for improving our safety in being established . These steps include doubling budgets available for Safer Streets which includes lighting and CCTV and the launch of pilot schemes to place safety in popular nightspots. “Victim blaming” has led to decades of women feeling guilty when harassed — being in the wrong place at the wrong time, what they were wearing, being too polite because maybe they inadvertently invited conversation with a smile. And we’ve seen this victim blaming with unwarranted comments questioning why Sarah was walking alone at night. Do you think we are now seeing a shift towards anger over victim blaming? What do you think the impact of this could be in making change? Paola: It is very easy to place blame on the victim. It is a quick way to refuse taking responsibility. It’s very sad that this happens, and because of this we see in the statistics that although the number of rapes has increased over the last few years, the number reported to authorities has decreased. In the last year the Crime Survey for England and Wales shows that 151,000 people — including 144,000 women — were victims of rape or attempted rape, but only 55,000 cases were reported to police. I think it’s because women (and victims in general) are fearful that the blame will go to them or they will not be believed, thus going through a second trauma — not only going through what you have suffered but re-living it and not being believed. The culprits who commit the crimes then feel they can get away with it because most victims do not report, out of fear of not being believed. It is a double failure. And walking is one of the few freedoms we still have left in the pandemic. What do you think the impact is of Sarah being abducted during this time? Paola: I think it’s a time which almost creates the perfect combination of factors for something like this to happen. Walking is the only thing we can do, and we’re not supposed to walk with friends because we shouldn’t meet with other people. It’s also a time when there are less people around to ask for help. People feel the only thing we can do has been used to bring blame to the victim, and this may explain why this event has been particularly impactful in the emotions it has caused. The loss of Sarah has been understandably very triggering for many women, it might remind us of previous experiences or tap into our biggest fears. What would you say to women who are feeling the impact of these conversations? Paola: I would say that the data — and indeed my and your experiences described in this blog — show that you are not alone. Most of us have been through the experience of being harassed to various extents. One thing that I believe we can say is that fear has affected 100% of us — even if we haven’t been harassed, we’ve all felt scared walking alone in the dark, we all live with the restrictions of what we can and cannot do. I would say: by all means, put in place whatever kind of safety measures you need to keep safe, but at the same time do keep talking about this: how unfair it is that you are restricted in your freedom. You need to talk about this in whatever context you can — talking to family, partners, colleagues, local politicians; and get involved in any organised action. As a society, we need to understand that this is a problem for all of us. In our conversation, we touched upon some statistics, and as shocking as these are, both Paola and I wanted to emphasise that fear is not captured in these numbers. We’ve all felt the constant threat, we have used the vigilance required to keep safe, and now we have all been reminded of this fear after hearing the shocking loss of Sarah. I feel sadness in knowing many have multiple experiences to recall; the horror of this should not be lost. I would like to thank Paola for sitting down and having this powerful conversation with me. As Paola said, I hope we can honour the memory of Sarah Everard and all women affected by, and lost to, such appalling crimes, by making the change that is so desperately needed. The conversation has started, let’s not let it go back. We should all be able to make it home safely. Our thoughts are with anyone close to or touched by Sarah Everard. If you feel particularly affected by the conversations happening and feel that you need help, please consider reaching out for support. This has been a very triggering time for many, depending on the level of distress, it may be helpful to talk to a professional or support group who will be able to help you. List of resources: Victim support  — Free confidential support for victims of crime or traumatic events Samaritans  — Support for anyone struggling Shout  — Text messaging support service for anyone struggling to cope Women and Girls Network  — supporting women and girls affected by gendered violence Ascent Advice line  — information, advocacy and support for gendered violence and abuse Rape Crisis  — Confidential and emotional support for victims of sexual violence Survivors Trust  — Directory of local support